U.S. Military Tobacco and Nicotine Policy Lagging Behind the Times

It has been nearly a decade since Secretary of Defense Ash Carter’s report issued a call for a tobacco-free military installations. Despite this, US military personnel continue to have among the highest rates of tobacco use in the US, and roughly 38% of military service members who smoke initiate use after enlisting. (1) Although tobacco use is a major public health issue among service members, progress towards achieving the Secretary of Defense’s call has been slow. This limited progress could be due to the misconception that the effects of tobacco use are long-term, whereas other health behaviors, such as drug use, alcohol abuse or not meeting weight standards, can have immediate effects on performance. Studies have documented that service members who smoke exhibit lower productivity than non-smoking counterparts, (2) miss more workdays, (3, 4) perform worse on their fitness tests, (5) and are more likely to be hospitalized. (3, 4) Since hundreds of thousands of service members use nicotine products and even more are exposed to these products in their work environments on a daily basis, there is a need for stricter policies in order to reduce tobacco use disparities among military service members.

Since the Surgeon General’s 2014 comprehensive review of military tobacco policy, (6) there have been several noteworthy policy updates. In 2014, the DoD published Directive 1010.10, an instruction to establish policy and assign responsibilities throughout the chain of command for health promotion and disease prevention. The document included instituting tobacco-free military housing areas and tobacco-free zones, restricting tobacco use from within 50 feet of building entrances and air ducts, establishing and restricting tobacco to designated tobacco use areas, and incorporating cessation services into routine health care (7). In 2016, the Secretary of Defense issued Policy Memorandum 16–001, which outlined sweeping tobacco policy reforms. The policy contained two key provisions related to tobacco pricing. Under this policy, all DoD stores are required to set all tobacco prices equal to prevailing local prices, adjusted for state and local taxes (1). This policy was a change from DoD Instruction 1330.09 which did not account for taxes (8). Additionally, this updated policy applied to all tobacco products, including e-cigarettes. (9, 10) These reforms were later incorporated into an updated version of directive 1010.10 (7). In late 2019, “Tobacco 21,” an amendment to the Federal Food, Drug and Cosmetic Act, raised the federal minimum age for purchasing tobacco from 18 to 21 years old (11). Unlike local and state tobacco pricing legislation, there were no military exemptions.

Despite the passage of these recent DoD-wide tobacco control policies, military culture, the physical environment, and political barriers have limited their impact. (12, 13) Furthermore, while the DoD’s comprehensive tobacco education and cessation program YouCanQuit2 continues to provide online resources, the DoD-affiliated Freedom Quitline (14) was discontinued in 2019. Given that the individuals in the U.S. military are particularly vulnerable to tobacco use due to their demographics, psychosocial risk factors, the stress of military deployment, (15, 16) and targeted marketing by the tobacco industry, (13, 17–18) there is a need for more stringent and innovative tobacco control policies to address tobacco health equity among US service members.

While DoD-level progress on tobacco control policies may have stalled, there has been headway made in local installation-level policy change which can act as a beacon to spur sweeping changes DoD-wide. Two such examples of effective installation-level policies or approaches enacted in recent years include prohibiting or limiting tobacco use among new trainees in the Army and Air Force during their advanced or technical training phase. While individual service branches took the innovative and progressive step of restricting tobacco use during basic training, these restrictions are largely not sustained beyond basic training. Research indicates that the period following basic training is a high-risk period for initiation and re-initiation of tobacco use following the protracted ban during basic training. (19–23)

In the first example, a large Army aviation training brigade on Fort Eustis (Virginia) implemented a nicotine-free policy in February 2020. This decision was based on data collected from trainees under their purview showing the benefits of the basic training policy and the high prevalence of use thereafter. The policy banned all tobacco and nicotine products for the up to 1,600 soldier trainees enrolled in advanced individual training (AIT, lasting 3–6 months on average) immediately following the 10-week basic training. (22) This policy significantly increased the length of time soldier trainees were in a nicotine-free environment at the beginning of their military career. The implementation of the policy was paired with appropriate tobacco prevention and treatment services for soldier trainees, including care packages [containing e.g., custom resource guide, tactile resources (chewing gum, toothpicks, stress ball, oral hygiene supplies)], and individualized pharmacotherapy. Gold standard treatment includes controller and reliever therapy, however the training setting is a unique environment. Here, pharmacotherapy should include controller therapy at a minimum, and while varenicline is superior to nicotine patches, tolerability in training may be an issue given varenicline should be taken after meals or will likely result in nausea. Reliever therapy may not always be appropriate during training given the rigorous nature and physicality of the schedule. Additionally, duration of treatment should be tailored to patient’s urges and cravings and comfort with discontinuation and should last a minimum of 3 months. (22) Individualized treatment was also offered to cadre (senior soldiers who work with the trainees, e.g. instructors, drill sergeants), in rolls such as drill sergeants and instructors, who showed high rates of current tobacco use at 30.8%. (23) Following the implementation of the policy, substantially more soldier trainees were interested in staying off nicotine products after AIT (47.5%) compared to prior to the implementation of the policy (29.9%, P < 0.01). This is particularly encouraging, given that there are no nicotine use restrictions in the period following AIT, providing evidence that long-term abstinence and subsequent outcomes may be improved by such a policy. (24)

In the second example, a large technical training squadron at Lackland Air Force Base (Texas) removed the designated tobacco use areas for trainees undergoing this training phase (approximately 3-months in duration) in July 2021. Removal of the designated tobacco use areas was implemented to mitigate the spread of COVID-19 and essentially eliminated their ability to use tobacco. Tobacco use data during this time were collected by the team as part of a larger study funded by the National Institute of Drug Abuse to understand the personal, interpersonal and environmental factors that lead Air Force technical trainees to initiate tobacco use during training (DA043468, PI Little). A total of 7,374 trainees aged 18 and older at Lackland Air Force Base were approached to participate in the study. Of those, 6,597 consented to participate and were surveyed about their tobacco use during their first and last weeks of technical training between October 2019 and February 2022. Study procedures were approved by the 59th Medical Wing Institutional Review Boards.

As seen in Figure 1, tobacco use at the end of technical training decreased among cohorts of Airmen exposed to the ban from 10.6% in June 2021 (prior to the removal) to 1.4% in September 2021. As the threat of COVID waned and enforcement of use was no longer deemed a priority, a steady increase in tobacco use occurred from the nadir in September until tobacco use areas were reincorporated in early 2022. Additionally, it is important to point out that Airmen may have been able to use non-combustible forms of tobacco, such as e-cigarettes and smokeless tobacco, in areas outside of the designated tobacco use areas, (25) making the removal of tobacco use areas less effective and potentially accounting for the increasing rates of use beginning in November 2021. Thus, it appears that this tobacco use mitigation strategy could have contributed to reduced tobacco use among Airmen undergoing technical training at this site.

Figure 1:

Tobacco use rates among Air Force trainees undergoing Technical Training in the U.S. Air Force at Lackland Air Force Base from April 2021 to May 2022

Note: The data were collected by the team as part of a larger study funded by the National Institute of Drug Abuse to understand the personal, interpersonal and environmental factors that lead Air Force Technical Trainees to initiate tobacco use during training (DA043468, PI Little). The tobacco use rates represent the percentage of airmen who smoked any form of tobacco products among all the participating airmen.

Given the effectiveness of these two local initiatives, and the potential impact decreasing tobacco use can have on mission outcomes, there is a clear benefit of the DoD extending nicotine-free periods. We recommend the DoD extend the tobacco and nicotine ban during basic training to encompass all initial training phases. Additionally, to prevent initiation and re-initiation of tobacco following protracted bans or during other high-risk periods, it is imperative that military service members be provided with comprehensive tobacco cessation services and treatment. (22, 26) The DoD has the ability to enact stringent tobacco control policies and the budget for the implementation of appropriate treatment. Not only can this significantly reduce the unnecessary burden of tobacco-related morbidity and mortality experienced by service members, (4) but could also broadly improve the health and wellbeing of the military force. When implementing more restrictive tobacco policies, it will be essential to address cultural, structural, and emotional barriers that perpetuate tobacco use among service members (e.g., addressing stress management, the need for social interactions without tobacco use, and accommodating other natural breaks in the duty day (27). Although some may argue that service members who are willing to risk their lives for our country should be able to choose to use tobacco, this is a false narrative that ignores the addictiveness of nicotine and the impact of decades of direct marketing by the tobacco industry to encourage tobacco use among service members. (13, 17–18) In sum, restrictive tobacco policies are profoundly patriotic by protecting the health and wellbeing of the military service members who bravely serve their country.